Healthcare Provider Details

I. General information

NPI: 1902185234
Provider Name (Legal Business Name): JMJ PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14125 SW FARMINGTON RD
BEAVERTON OR
97005-2567
US

IV. Provider business mailing address

16055 SW WALKER RD SUITE 114
BEAVERTON OR
97006-4942
US

V. Phone/Fax

Practice location:
  • Phone: 503-430-8161
  • Fax: 503-640-6182
Mailing address:
  • Phone: 503-430-8161
  • Fax: 503-640-6182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1624
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2212
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number891
License Number StateOR

VIII. Authorized Official

Name: DR. LUZ MARTHA CALLUM
Title or Position: PSYCHOLOGIST
Credential: ED.D.
Phone: 503-430-8161